This Week's Headlines:

Homicide Ruling in ED could Chill Disclosure, Just Culture

Maybe you've been working hard for a few years now to convince staff that they can speak up about adverse events and threats to patient safety, and you know that it takes time to get that message across. But what if one extreme case comes along that undercuts all of your efforts?

That could be what is happening with the homicide ruling related to a death in the emergency department at Vista Medical Center in Waukegan, IL. The deputy coroner has ruled that the death of a 49-year-old woman who waited almost two hours after complaining of nausea, shortness of breath, and chest pains was a homicide. She was seen by a triage nurse about 15 minutes after she arrived, and the nurse classified her condition as "semi-emergent." When nurses came back to check on the woman two hours later, she was dead. A coroner's jury declared it a homicide, which means that the triage nurse involved could be criminally prosecuted.

While the county district attorney's office has not taken any action yet in response to the homicide ruling, observers say even the possibility of a criminal charge could have a devastating effect on risk management efforts to encourage more open communication about patient care.

Gregory L. Henry, MD, FACEP, risk management consultant for Emergency Physicians Medical Group in Ann Arbor MI, notes that the damage already is done, regardless of whether the local prosecutor decides to take action on the homicide ruling. Following through with criminal charge against the nurse would only make the problem worse. Simply declaring the death a homicide creates a fear of prosecution among all involved in the case, he says, and the natural response will be for staff to become more guarded and fearful. That response could result in closer attention to patients who show up in the emergency department with similar symptoms, but the more likely result is that staff will become fearful that they could be made scapegoats by family members and a legal system that doesn't understand the realities of emergency medicine.

For risk managers, Henry says the worst effect from such homicide rulings may be the unraveling of efforts to encourage people to speak up about adverse events. It was hard enough to get people to speak up when their jobs or their reputation was on the line, but the challenge is much greater if people think they actually could be charged with murder. The natural tendency is to just lie low and not make yourself a target by speaking out, he says.

There may be no easy solution to that dilemma, but it is one more example of why risk managers are needed in a health care system. With coroners ruling homicide after a long wait in the emergency department, there will always be work for risk managers in countering the understandable inclination of staff to keep quiet about adverse events. (The April issue of  Healthcare Risk Management will offer additional coverage of this topic.)

— Greg Freeman, editor

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Doctors Not Eager to Tell Patients About Debatable Treatment

Do you have physicians who dance a little too close to the edge of what is legal and ethical when it comes to treatments that are not universally accepted by the medical community? Would you be happy to learn that a physician told the patient enough to technically comply with obligations, but not really enough for the patient to be fully informed?

That situation could be happening at your facility, according to a recent report from researchers at the University of Chicago in the New England Journal of Medicine.(Reference 1) They say many physicians feel no obligation to tell patients about legal but morally controversial medical treatments or to refer patients to doctors who do not object to those treatments.

The medical profession appears to be divided, the researchers note, not just in its attitudes about providing controversial practices such as terminal sedation, abortion or birth control for teens, but also in its judgments about what doctors should do when patients request a legal procedure to which their doctor objects.

The study found that although 86% of doctors did feel obliged to present all options in such cases, only 71% said they would feel obligated to refer the patient to a doctor who did not object to the requested procedure, and 63% believed it is ethically permissible for a doctor to describe his or her objection to the patient.

This situation affects millions of people, the authors note. "If physicians' ideas translate into their practices, then 14% of patients — more than 40 million Americans — may be cared for by physicians who do not believe they are obligated to disclose information about medically available treatments they consider objectionable," the authors write. "In addition, 29% of patients — or nearly 100 million Americans — may be cared for by physicians who do not believe they have an obligation to refer the patient to another provider for such treatments."

The researchers mailed a 12-page questionnaire to 2,000 physicians from all specialties; 1,144 (63%) responded. They asked physicians if they had objections to three controversial clinical practices. Only 17% objected to terminal sedation (sedating dying patients to the point of unconsciousness), but 42% objected to prescription of birth control to teen-agers without parental consent, and 52% objected to abortion for failed contraception.

They also asked physicians about their sense of obligation when patients request such procedures. Should physicians "present all possible options?" May a physician who objects to a procedure "plainly describe why?" If the physician objects, does he or she "have an obligation to refer the patient to someone who does not object?"

In comparison to the 86% who felt obliged to present all possible options, 6% were undecided, and another 8% felt no such responsibility. While 63% felt it was ethical to "plainly describe" why they objected to a requested procedure, 18% felt no obligation to refer a patient to another doctor who did not object. Another 11% were undecided about their responsibility to refer.

Reference

1. Curlin FA, Lawrence RE, Chin, MH, et al. Religion, Conscience, and Controversial Clinical Practices. NEJM 356:593-600.

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Radiology Service Pulls Out of Baltimore Hospitals Due to Malpractice Costs

Hospitals in Baltimore, MD, are facing a crisis brought on by climbing malpractice costs. American Radiology Services in Pikesville, is one of two large radiology practices based in the county that plans to withdraw their services from two hospitals in Baltimore in April, in part because of higher malpractice costs in the city, the Owings Mills (MD) Times reports.

American Radiology Services will terminate services to Good Samaritan Hospital in northeast Baltimore. Representatives at Good Samaritan Hospital, part of the MedStar Health system based in Columbia, said the hospital has reached an agreement with Baltimore Imaging Centers, also based in Pikesville, to provide radiology services after American leaves.

Woodlawn-based Advanced Radiology also will stop providing services to St. Agnes Hospital in southwest Baltimore. In 2005 the practice's malpractice premiums were five times what they were in 2000, according to Robert Stroud, MD, president of Advanced Radiology and also a practicing radiologist. "Baltimore city juries tend to be more sympathetic to the plaintiffs," he told the newspaper. "Lawsuits are more easily defensible in other jurisdictions."

Advanced Radiology assigns about 10 radiologists to St. Agnes who provide emergency department coverage 24 hours a day and other services. The practice is the only source of radiologists for the hospital. Replacing them could be difficult because of a national and local shortage of board-certified radiologists.

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